Republic of the Philippines)

Santa Cruz, Laguna ) s.s.

AFFIDAVIT OF LOSS
OF PHILIPPINE PASSPORT

I, JANICE A. DALAGAN-BETE, of legal age, Filipino, married and a

resident of 0140 Aurora Homes, Brgy. Calios, Santa Cruz Laguna, after
having been duly sworn to in accordance with law, depose and state THAT:

1. I am a bonafide passport holder, specifically Passport No. LL655827

issued on 24 July 2003 by the Department of Foreign Affairs, Manila. No
other passport was ever issued to me again.

2. On or about June 2005, I discovered that my said passport was

inadvertently lost/missing;

3. Despite diligent search and efforts to locate the said passport, I could not
find the same such that I believe that it is now lost beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and

to support the application for the issuance of a new one in lieu of the one
which was lost.

IN WITNESS WHEREFORE, I have hereunto set my hand this 17

September 2016 in Santa Cruz, Laguna, Philippines.

JANICE DALAGAN-BETE
Affiant

SUBSCRIBED AND SWORN to before me this 17 September 2016 by

the affiant with Laguna Governor’s Office Employee I.D. No. 20100701-2205-
C, issued at Provincial Capitol of Laguna.

Doc. No. _____; A T T Y. E M M A N U E L E . S A N D I C H O

Page No._____; NOTARY PUBLIC, COMMISSION UNTIL 31 DEC. 2016
Book No._____; NOTARY PUBLIC FOR THE PROVINCE OF LAGUNA
Series of 2016. PER NOTARIAL COMMISSION SP. PROC. NO. 164(15)
IBP O.R. No. 995689, 04 January 2016, Laguna Chapter
PTR O.R. No. 2967138, 04 January 2016, Laguna
Roll No. 42246, admitted to practice law on 9 May 1997
MCLE Compliance No. V-0015412, dated 6 March 2016